Caseload midwifery – where do you get it?

In Australia, the growing popular choice for expecting mothers is to stick with one midwife from pregnancy to post-natal care. Anne Marie George looks at why caseload midwifery has more to offer than a boutique service.

In some maternity units, mothers-to-be are fortunate enough to know the name of their midwife well before they go into labour. Chances are they booked their maternity care with a hospital which uses the caseload model of midwifery. Midwives love it, mothers love it but most hospitals in Australia are yet to offer it in numbers that meet the demand.

A one-on-one service might be best for midwives and patients./Photo: PAHO/WHO / Foter / CC BY-ND

Under the alternative “standard care” model, women see whichever midwife is rostered on at the hospital. Often, this means that they will encounter a number of midwives and obstetric staff throughout their pregnancy, and will likely undergo the deeply personal, emotional and exposing experience of childbirth with someone who knows nothing of them other than some hastily read clinical notes.

Maralyn Foureur, professor of Midwifery at the University of Technology, Sydney (UTS), said that the caseload model does not only provide a more familiar experience for the patient, but saves the hospital money.

“Covering shifts 24/7 is very wasteful of staff – but it is the only way we know so it continues to be done. This model is much more cost-effective, she said.”

“We need the state and federal governments to step in and mandate for change so that childbearing women and babies can reap the benefits.”

While caseload midwifery as previously been thought of as a “boutique” service, there is research supporting its benefits. An Australian study recently published in the Lancet showed that caseload midwifery lowers service costs. In a randomised controlled trial jointly conducted at the Royal Hospital for Women (Sydney) and the Mater Mothers Hospital (Brisbane), women in the caseload cohort required less interventions during labour, used less painkillers and had less visits during pregnancy than the standard care group.

But the concept isn’t new in Australia. Twenty-five years ago renowned obstetrician, Roger Shearan, headed a review on midwifery services in NSW and found that women wanted continuity of midwifery care. Since then, both federal and state governments have supported this approach.

Yet, according to Helen McLachlan, associate professor in Midwifery at La Trobe University, the model is currently offered to only about 10 per cent of women in Australia. Speaking last year on the impressive results of the largest clinical trial of the caseload model (a COSMOS study), she was hopeful that the mounting evidence might turn the tide.

“There were 22 per cent less caesarean sections, therefore less surgery costs, reduced length of stay and even less sick-leave for midwives. These results should give confidence to hospital administrators to implement this model,” she said.

Caroline Homer, professor of midwifery at UTS, believes that the main barrier is resistance to organisational change. Under a unique award negotiated by the NSW Nurses and Midwives’ Union, caseload midwives are employed to work 160 hours a month, and take on a caseload of 40 women a year. This averages to about 40 hours a week and 4 women a month.

Typically, they would belong to a Midwifery Group Practice (MGP) of four midwives, which provides backup if needed. How each midwife manages their hours and visits is entirely up to the group and its patients.

As professor Homer notes, it is a radical departure from rigid hospital rosters. “If I manage a standard labour ward, on any given morning, I know I’ll have three midwives on my roster and that’s really comforting,” she said.

“The caseload midwives are not going to appear at seven in the morning and wait for people to arrive – they only appear when their women are in labour. It’s hard for hospitals which run on military precision basis to get their head around that level of uncertainty and flexibility.”

But some hospitals do get their heads around it, and it takes good leadership to get there. At the Royal Hospital for Women in Sydney, almost half of their maternity bookings are now midwifery group practices. Sally Tracy, professor of midwifery at the University of Sydney, joined The Midwifery Research Unit at the Royal Hospital for Women in 2008. Since then, the hospital has adopted the caseload midwifery model but the move was not easy.

“The ward is staffed with fewer midwives and when needed the caseload midwives come in with their women. It has continued to work this way. The overtime hours have reduced enormously and we hardly ever have to call on agency staff,” she said.

Professor Foureur agreed that caseload is a more efficient way to organise shifts.

“Everyone forgets that we have to staff a maternity unit fully even if there is no woman admitted in labour so often the midwives are filling in time waiting for a woman to arrive -or the converse -they are understaffed because they are covered only by the minimum required of hospitals, she said.

Foureur referred to New Zealand, where 80 per cent of women receive this model of care after a government-enacted legislation in 1991.

Midwives who have moved from standard care to a caseload practice are unlikely to go back. One caseload midwife from Sydney said that the flexibility and autonomy to adapt hours and location to a woman’s particular needs serves both parties well.

“I can go in to the hospital when I want, I can leave when I want, I can see the women in their own homes, or in the hospital if it suits them and it suits me. The bottom line is, when the woman is in labour, or if there’s a problem and she needs me, that’s when everything stops and that’s what I do,” she said

Being the on-call midwife for a woman for months, until the delivery and after, also creates a comfort level, “It’s much easier to get up at three in the morning to deliver a baby for someone you know.”

So what will it take for caseload to become the norm? Professor Homer says more pressure needs to be applied at many levels – starting with women realising that waiting in a clinic all morning, for a visit with someone they don’t know, isn’t good enough anymore.

“It’s all about activating consumer demand,” Homer said. “The Australian College of Midwives will be flooding GP surgeries with posters promoting continuity-of-care, and women will have to start saying, “I want caseload, what’s the hospital going to do about it?”

“We’re getting to a tipping point,” she said, “certainly in the last five years the number of services have increased and will keep increasing, but we need to keep plugging away.”